Complaint Investigation Report

(2) staff. According to the complaint, it was alleged that R1 eloped due to a lack of staff supervision, resulting in R1 being left unattended in various locations within the surrounding neighborhood. However, interviews conducted with staff and residents did not corroborate the allegation. Staff, including the Administrator, reported that R1 enjoys spending time outdoors and taking walks. Staff indicated they are aware that R1 cannot be left unattended and stated that staff either accompany R1 on walks around the neighborhood or remain with R1 while outside.

Residents interviewed reported observing staff accompanying R1 outdoors and stated they have not witnessed R1 leaving the facility unattended or eloping. Although the allegation of lack of supervision resulting in R1 eloping was reported, based on the information obtained through interviews, the allegation may have occurred; however, there is insufficient evidence to support the validity of the claim at this time. Therefore, the allegation is determined to be Unsubstantiated.

Allegation # 2: Facility staff do not adequately supervise residents in care. Concerns were expressed that facility staff do not adequately supervise residents in care. To investigate the allegation, on 07/25/2025 and 07/28/2025, at various times between 9:30 a.m. and 12:30 p.m., the Licensing Program Analyst (LPA) conducted interviews with the reporting party and other witnesses associated with the complaint. On 08/01/2025, from 9:00 a.m. to 1:00 p.m., the LPA conducted an initial complaint visit, which included a physical plant inspection, as well as interviews with three (3) staff and three (3) residents. During today’s visit, from 12:00 p.m. to 12:30 p.m., LPA conducted additional interviews with two (2) residents and one staff. According to the complaint, it was alleged that staff failed to adequately supervise residents. Specifically, it was reported that staff were observed running after resident #1 (R1) and asking neighbors for assistance in retrieving R1. It was further alleged that R1 fell in a neighbor’s yard and staff were unable to assist R1 off the ground without help from a neighbor. However, interviews conducted with staff and residents did not corroborate the allegation. Staff, including the Administrator, reported that R1 enjoys sitting on a bench located in a neighboring yard. Staff stated they are aware that R1 cannot be left unattended and indicated they remain with R1 while in the neighboring yard. Staff denied that R1 fell and denied requesting assistance from neighbors to help R1 off the ground. Staff reported that they accompany R1 at all times while outdoors and do not allow R1 to remain unattended. Staff also indicated that neighbors have not expressed concerns regarding R1 being in the yard.